Blueprint II Improving mental health and wellbeing for all New Zealanders. How things need to be. June 2012 Mental Health Commission

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1 Blueprint II Improving mental health and wellbeing for all New Zealanders How things need to be June 2012 Mental Health Commission

2 Citation: Mental Health Commission Blueprint II: How things need to be. Wellington: Mental Health Commission. Published in June 2012 by the Mental Health Commission Wellington, New Zealand Blueprint II: How things need to be ISBN: Cover & masthead designs inspired by Athina Moisa, Pablos Art Studio This document is available on the Health and Disability Commissioner s website:

3 1. Treaty Implications As the founding document of New Zealand, Te Tiriti o Waitangi must be acknowledged and its principles incorporated in all aspects of health services provision for all New Zealanders, and in particular for tangata whenua. The Mental Health Commission acknowledges the significance of the Treaty as the original blueprint for interactions between the Crown and tangata whenua. 1.1 Article One Article One places an obligation on the Crown to consult and collaborate with iwi, hapu and Māori, as tangata whenua, in order to determine their attitudes and expectations with regard to the functions and operation of good government. With regard to the public funding and provision of mental health and addiction services, this requires meaningful consultation with Māori, and Māori involvement in the planning of those services. 1.2 Article Two Article Two guarantees Māori rights of ownership, including non-material assets such as te reo Māori, Māori health and tikanga Māori, and confirms the authority of iwi, hapu and Māori, as tangata whenua, over their own property, assets, and resources. Article Two establishes the principle of tino rangatiratanga self-determination and jurisdiction for Māori communities and organisations such that they can manage their own property, assets and resources. This article directs agents of the Crown to negotiate directly with iwi, hapu and whānau with regard to policy which impacts on them. Tino rangatiratanga can be acknowledged through specification of kaupapa Māori services and providing Māori with increased opportunities to create and implement strategies and services which will improve mental health and addiction services, and mental health and wellbeing outcomes for Māori. 1.3 Article Three Article Three guarantees Māori the same rights of citizenship and privileges as British subjects, including the rights of equal access to mental health and addiction services, to equal health and wellbeing outcomes and to access mainstream mental health and addiction services which meet the needs of Māori. Blueprint II provides a strong call for equity of participation, access, and outcomes, and acknowledges that while there has been a significant improvement over the past decade, these goals are not being achieved at present. Treaty Implications 1

4 2. Mihi E tū ake nei tō tātou whare whakahirahira Ko Ranginui e tū ake nei hei tuanui Ko Papatūānuku e takoto nei hei whāriki Ko te reo me ngā tikanga hei tāhuhu Ko te iwi hei poutokomanawa E tū e te whare e! Hei whakairi i ō tātou wawata, ō tātou tūmanako, ō tātou moemoeā! There stands our house in all its grandeur The sky is its roof The earth is its carpet Our language and culture is its ridge pole And the people stand at its centre Stand erect! So that you may house our hope and dreams within! 2 Blueprint II: Improving mental health and well being for all New Zealanders How things need to be

5 3. Foreword from the Mental Health Commissioners Since the launch of Blueprint for Mental Health Services in New Zealand: How things need to be (1998) 1, support for people with complex and enduring mental health and addiction problems and their family and whānau has come a long way. There has been major investment in developing specialist services based on recovery models that have gained international recognition. It is now timely to focus on what needs to happen over the next decade. Blueprint II builds on past achievements and provides a pathway to a future in which mental health and wellbeing becomes everybody s responsibility. It is widely accepted that everyone is responsible for managing their own physical health and fitness, and we need the same acceptance of responsibility for mental health and wellbeing. It is the only way individuals and their families and whānau can improve their ability to weather adversity and to achieve their own aspirations. At the same time, we need to greatly expand access to services by doing things differently and making the most of all our collective resources. Blueprint II is based on the concepts of people-centred and people-directed recovery and resiliency as core values and creates an environment where all of us involved in mental health and addiction can do more with the funds, workforce, infrastructure and energy we already have. It builds on our considerable strengths in specialist services and provides direction and support to create better access and responses across the life course and across the broader health and social sectors. The expert advice from the sector and feedback from the consultation process has provided a sound foundation for determining how the future needs to be and how to make it happen. As this is the Mental Health Commission s final publication, we would like to pay tribute to everyone who has supported us and our work over the past 16 years. We are entering a new phase of development for mental health and addiction services with the disestablishment of the Commission and the transfer of our core functions to the Office of the Health and Disability Commissioner. Responsibility for championing the themes in Blueprint II will need to be taken up by as many individuals and organisations as possible in order that these changes happen. Tawhiti rawa atu to tatou haerenga te kore haere tonu, maha rawa atu o tatou mahi te kore mahi tonu, Ta Hemi Henare We have come too far not to go further, we have done too much not to do more. Lynne Lane Chair Commissioner Ray Watson Commissioner Bice Awan Commissioner 1 Mental Health Commission. November Blueprint for Mental Health Services in New Zealand: How things need to be. Wellington: Mental Health Commission. Foreword from the Mental Health Commissioners 3

6 4 Blueprint II: Improving mental health and well being for all New Zealanders How things need to be

7 Contents 1. Treaty Implications Article One Article Two Article Three Mihi Foreword from the Mental Health Commissioners Executive Summary From Blueprint to Blueprint II Acknowledging our success to date Building on our success Vision Principles Directions Respond earlier and more effectively to mental health, addiction and behavioural issues Improve equity of outcomes for different populations Māori Pacific peoples Increase access to organised mental health and addiction responses Increase system performance and the effective use of resources Stepped care A no wait system Modify the way the sector is funded Improve partnerships across the whole of government Priority Actions Providing a good start Positively influencing high risk pathways Supporting people with episodic needs Supporting people with severe needs Supporting people with complex needs Promoting wellbeing, reducing stigma and discrimination Providing a positive experience of care Improving system performance Workforce Funding and commissioning What Will Success Look Like Population level monitoring Service level monitoring Appendix 1: Response Level Estimates Appendix 2: How Blueprint II was Developed Appendix 3: Glossary of Terms and Abbreviations...45

8 4. Executive Summary Blueprint II champions a bold new vision to improve the mental health and wellbeing of all New Zealanders. It is a ten year vision that encompasses all of government and provides guidance on what is required to meet future needs and how to make the changes called for. It is independent, evidence-based advice from the Mental Health Commission that has been informed by engagement with the health and disability sector and with consumers and their family and whānau. Why change is needed The first Blueprint 2 successfully championed the recovery approach and the drive to provide access to services for the 3% of people most seriously affected by mental health and addiction issues. We are now increasingly aware of the needs of those who have a lower level of need but whose mental health and addiction issues impact significantly on their overall health and their ability to function at home or at work. We are also more aware of the significant benefits of early recognition and response, as well as the importance of working across the whole health sector and other government agencies to achieve the best outcomes for people and for society. We still have one of the highest rates of youth suicide in the developed world and inequalities in mental health and addiction outcomes for Māori and Pacific people. What Blueprint II will achieve The Blueprint II vision mental health and wellbeing is everyone s business sets the stage for a future where everyone plays their part in protecting and improving mental health and wellbeing. It is founded on the understanding that mental health and wellbeing plays a critical role in creating a well-functioning and productive society. When Blueprint II is implemented: People who have mental health and addiction issues will not have to wait for support at a level of intensity that matches their need. People and their family/whānau will be partners in the care process. People and their family/whānau will experience support that is designed around their needs and where every contact with a service supports their return to health, functioning and independence. People s mental health and addiction issues will be recognised and treated early across the whole life-course. More people will experience good mental health as a result of cross government and community action to enhance the protective factors that determine mental wellbeing (for example, social inclusion, income, employment, education, housing, and absence of discrimination). Differences in outcomes for different population groups will be significantly reduced. We will have transformed our system performance and reduced the average cost of care, resulting in significantly increased access to services for a much broader range of people. 2 The Mental Health Commission. November Blueprint for Mental Health Services in New Zealand: How things need to be. Wellington: The Mental Health Commission. 6 Blueprint II: Improving mental health and well being for all New Zealanders How things need to be

9 Blueprint II priorities Blueprint II identifies eight priorities: Providing a good start: Respond earlier to mental health and addiction issues in children and young people to reduce lifetime impact. Positively influencing high risk pathways: Provide earlier and more effective responses for youth and adults who are at risk or involved with social, justice, or forensic mental health and addiction services. Supporting people with episodic needs: Support return to health, functioning and independence for people with episodic mental health and addiction issues. Supporting people with severe needs: Support return to health, functioning and independence for people most severely affected by mental health and addiction issues. Supporting people with complex needs: Support people with complex combinations of mental health issues, disabilities, long term conditions and/or dementia to achieve the best quality of life. Promoting wellbeing, reducing stigma and discrimination: Promote mental health and wellbeing to individuals, families and communities and reduce stigma and discrimination against individuals with mental illness and addictions. Providing a positive experience of care: Strengthen a culture of partnership and engagement in providing a positive experience of care. Improving system performance: Lift system performance and reduce the average cost per person treated while at the same time improving outcomes. Making change happen We need to do things very differently if we are to extend access to a broader range of mental health and addiction responses and develop a no wait system which provides early and timely responses. The results that Blueprint II is seeking can t be achieved by making minor changes. We need to make substantial changes to the level and mix of services provided as well as where and when we intervene. It means a greater role for primary care and changes in the way our workforce is used. An important component of this change will be the full implementation of a stepped care approach intervening in the least intensive way from self care and across primary, community and specialist services to get the best possible outcomes. The mental health and addiction ringfence has helped the sector grow and improve access rates and services, particularly for people with the highest level of need. To support the changed models of care and to extend access to a broader range of people, the ringfence now needs to be modified. More flexibility in the way that ringfenced funds can be used will help extend access and integration. And a move from an historical to a population-based ringfence will better reflect the size, makeup and need of each DHB. At the same time it will be important to put in place a results-based performance framework and new performance targets to provide assurance that the new flexibility is being used to best effect. In 3 5 years, when the new performance framework is in place and working well, the need for continuing the ringfence should be reviewed. This document, Blueprint II: How things need to be, has a companion document, Blueprint II: Making change happen. It provides practical guidance on how to make Blueprint II a reality and is available online at Measuring progress The two key statutory roles of the Mental Health Commissioner, as part of the Office of the Health and Disability Commissioner, are monitoring and advocacy. Promoting Blueprint II and monitoring progress on its implementation will be a priority. This will include sector visits and regular public reporting against a set of indicators that provide information on achievements at both a population level and a service level. Executive Summary 7

10 5. From Blueprint to Blueprint II The first Blueprint, 3 published in 1998, successfully championed the recovery approach and the drive to provide access to services for the estimated 3% of people most seriously affected by mental health and addiction issues. We now have one of the better specialist mental health and addiction sectors in the world. The time has come to broaden our focus. We have new knowledge about what works and what does not, and our environment has changed and will continue to change. Blueprint II is an independent, sector-informed vision that aims to build services that meet our future needs. It also provides guidance to the mental health and addiction sector, the broader health sector and inter-agency partners on how to make the changes needed over the next decade. Like the original Blueprint, Blueprint II is not government policy. It is independent advice from the Mental Health Commission to Government and it is guidance from the Commission to government agencies. The Ministry of Health is leading the development of a five-year Service Development Plan, 4 which will articulate government policy on developments in health-funded services. The Service Development Plan is expected to be informed by Blueprint II. Together, Blueprint II and the Service Development Plan will help the broader health and government sectors build on their current strengths to address future challenges. 5.1 Acknowledging our success to date Over the past two decades New Zealand s mental health and addiction sector, guided by progressive national strategies and policies, has been improving the way it meets the needs of service users and family/whānau. The mid to late 1990s saw the publication of the National Mental Health Strategy, Looking Forward, (1994) 5 together with its action plan, Moving Forward (1997) 6 and the Mental Health Commission s Blueprint (1998). Collectively these made mental health and addiction a priority for the Government and supported the sector to: Steadily grow access to specialist services and to grow sector capacity and infrastructure. Strengthen the voice of service users and their say in how services are planned and developed. Shift the mix of care, with far fewer people treated in institutions and many more supported in their recovery within the community. Grow the non-governmental (NGO) sector including Māori and Pacific providers. Move from relative under-investment in mental health and addiction services. From 1994 to 2005 the sector s focus was necessarily on people most severely affected by mental health and addiction issues (the 3% ) and the specialist services that supported them. There was also growing acknowledgement of the significant impacts of mental health and addiction right across society, the needs of those with mild and moderate symptoms, and the importance of early intervention, prevention and the 3 The Mental Health Commission Blueprint for Mental Health Services in New Zealand: How things need to be. Wellington: The Mental Health Commission. 4 Ministry of Health Draft Service Development Plan. Due for publication December Ministry of Health Looking Forward. Strategic Directions for the Mental Health Services. Wellington: Ministry of Health. 6 Ministry of Health Moving Forward. The National Mental Health Plan For More and Better Services. Wellington: Ministry of Health. 8 Blueprint II: Improving mental health and well being for all New Zealanders How things need to be

11 promotion of mental wellbeing. The mental health and addiction strategy TeTahuhu ( ) 7 and its associated action plan, Te Kokiri ( ), 8 sought to significantly broaden the focus of the mental health and addiction sector to move beyond the most severely affected. It also identified the need to integrate mental health and addiction services into the broader health system and across social services. Since 2005 there have been some significant developments, including an increasing number of primary mental health initiatives, highly successful mental health promotion and self-help activity (for example, the destigmatisation campaign, Like Minds Like Mine 9 and the National Depression (fronted by John Kirwan), ongoing increases in access rates to specialist services (which now sit at a national average of 3.1%) and a greater focus on addiction services (both as part of, and separate from, mental health services). In addition, other government agencies have increased their focus on mental health and addiction; for example, launching initiatives influencing the drivers of crime, improving outcomes for children in care and young people, and assisting people with mental health and addiction issues back into the workforce. 5.2 Building on our success We are now at a critical point in the evolution of the mental health and addiction sector. The population of New Zealand is changing: overall, it is increasing in size and ethnic diversity and aging. The health promotion and public health initiatives (for example, Like Minds Like Mine ) that have been in place for a number of years continue to change people s expectations of services, their knowledge of what is available and how to seek help. The argument for continuing to invest in mental health and wellbeing is strong. There is increasing awareness that: Mental health and addiction issues are more common than typically recognised. The personal impacts of poor mental health are higher than any other group of diseases, and the societal impacts reach far beyond just the affected individual or the health sector. Early recognition and treatment of mental health and addiction issues can significantly reduce the negative impact on people, their families and whānau, communities and wider society. The mental health and addiction sector has a role to play in forming strong links and partnerships with agencies that are addressing broad government objectives where mental health and addiction issues play a significant role; for example, reducing sickness benefits. There is a strong link between poor mental health, addiction and poor physical health. In the words of the World Health Organization 10 there is no health without mental health. Treating one area in isolation limits the benefits that can be achieved. The personal impacts of mental health and addiction disorders are significant: they are the leading cause of disability and result in significantly reduced life expectancy. It is estimated that people with severe mental illness live an average of 10 to 15 years less than people without mental illness. 11 We have one of the highest rates of youth suicide in the developed world. 12 Mental health and addiction outcomes for Māori and Pacific people prevent them experiencing the same levels of wellbeing as the rest of the population. 7 Ministry of Health TeTāhuhu: Improving Mental Health. Wellington: Ministry of Health. 8 Ministry of Health TeKokiri: The Mental Health and Addictions Action Plan Wellington: Ministry of Health. 9 Ministry of Health Like Minds Like Mine. 10 World Health Organization Mental Health: New Understanding, New Hope. Geneva: World Health Organization. 11 Chang C-K, Hayes R D, Perera G, Broadbent M T M, Fernandes A C, et al Life Expectancy at Birth for People with Serious Mental Illness and Other Major Disorders from a Secondary Mental Health Care Case Register in London. PLoS ONE. 6(5): e doi: / journal.pone Ministry of Health Suicide Facts: Deaths and Intentional self harm hospitalisations Wellington: Ministry of Health. From Blueprint to Blueprint II 9

12 The combined impact of these factors will require the sector to increase access to organised mental health and addiction responses over the next 10 years. Increasing access is relatively easy if we increase resources. But as we know, the constrained fiscal environment is expected to continue for some time. We have a choice. We could continue as we are: delivering specialist support to those who access services and working on areas that still require improvement. Or we can be bold, in the same way that the initial Blueprint was bold, and commit to a vision and a road map for change that will create a new wave of development for the mental health and addiction sector. This new wave is built on an understanding of the interaction between mental health and addiction, physical health and a person s social context. It provides insight into how a person s context and history can shape their mental health. 13 We are not starting from scratch. New Zealand has already begun to embrace this new wave. People with experience of mental health issues or addiction already have greater involvement in designing and improving their own treatment plans. We have improved our focus on preventing mental illness and intervening earlier and there is a growing awareness of recovery, resilience and Whānau Ora models. We have a broad range of modern services, including peer support, and successful health promotion programmes. There is growing awareness across government agencies of the role they can play in improving mental health and wellbeing; for example, in areas such as housing, income and work. There is also awareness that mental health and addiction issues in some people can impact on educational achievement, crime and sickness benefits; for example, of the 58,000 on sickness benefits, 41.5%, or 24,070 people, have psychological or psychiatric conditions as the main incapacity or reason for being on the benefit. 14 For the 84,000 on the invalid s benefit this is 30.4%, or 25,536 people Vision Blueprint II s vision is to make mental health and wellbeing everyone s business. It is a vision founded on a common understanding that mental health and wellbeing plays a critical role in creating a well-functioning and productive society. It is a vision for a future where everyone plays their part in protecting and improving mental health and wellbeing. Whole of... Family / Government Health Community Person Whānau 13 World Health Organization The Mental Health Context. Geneva: World Health Organization. 14 Centre for Social Research and Evaluation National Fact Sheet Sickness Benefits. Wellington. Ministry of Social Development. 15 Centre for Social Research and Evaluation National Fact Sheet Invalids Benefits. Wellington. Ministry of Social Development. 10 Blueprint II: Improving mental health and well being for all New Zealanders How things need to be

13 This is a vision where: People, families/whānau and communities are well informed and have the tools to actively develop their own ability to weather adversity. Primary and other general health care services support resilience, recognise emerging problems early and provide the supports and interventions to enable people to recover rapidly. Mental health and addiction responses support and enable recovery and full participation. Publicly funded agencies work together to make the best use of their collective funds to achieve the best possible outcomes and where governments of the day create a policy environment that supports this joined-up approach. 5.4 Principles The recovery approach articulated in the initial Blueprint has guided service development over the past decade for those most severely affected by mental health and addiction issues. Blueprint II reinforces and strengthens the recovery principle alongside the principles of resiliency and a people-centred and directed approach. A people-centred and people-directed approach A people-directed approach is one where there is real partnership between people with mental health and addiction issues, their family/whānau and their service provider. This model is already well developed in New Zealand. Blueprint II seeks to make it stronger. There is a need for stronger partnerships, self-determination, information, and involvement in providing services, shaping and overseeing policy and being part of services development at a national level. There is evidence across the broader health sector of significant benefits from partnerships between health services, health professionals and services users, their families/whānau in clinical quality and outcomes, the experience of care, and the business and operations of delivering care (including reduced costs) And from a human rights perspective it is essential. A people-centred approach is one where responses are designed around a person s needs rather than around the needs of those providing service. It is one where every contact a person and their family/whānau have with services uses a recovery approach and supports their engagement and care for their own mental health and wellbeing. Recovery and resiliency Resiliency is the capacity of individuals to cope well under adversity. A resiliency approach encourages individuals to build the capacity to care for their own mental health. It encourages social inclusion as an important tool for reducing the impact of mental health and addiction issues and supports families and communities to take part in that process. Recovery is commonly defined as living well in the community with natural supports. Recovery does not always mean people will return to full health or retrieve all their losses, but people can and do live well despite this. The description of recovery continues to evolve. Destination notes that the recovery philosophy stresses hope, self determination, full citizen participation and a broad range of services and resources for people with mental disorders. 20 Our Lives in 2014 describes recovery as being something that happens when we regain personal power 16 Meterko M, Wright S, Lin H, et al Mortality among patients with acute myocardial infraction: The influences of patient-centred care and evidence-based medicine. Health Services Research. 45(5p1): Charmel P, Frampton S Building the business case for patient-centred care. Healthcare Financial Management. March 62(3): Boulding W, Glickman S, Manary M, et al Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. The American Journal of Managed Care. 17(1): DiGiola A, Greenhouse P, Levison T Patient and family-centred collaborative care: An orthopaedic model. Clinical Orthopaedics and Related Research. 463(13 19). 19 Arbuthnott A, Sharpe D The effect of physician-patient collaboration on patient adherence in non-psychiatric medicine. Patient Education and Counseling. 77(1): Mental Health Advocacy Coalition Destination: Recovery: TeŪngaki Uta: Te Oranga. Auckland: Mental Health Foundation of New Zealand. From Blueprint to Blueprint II 11

14 and a valued place in our communities. Sometimes we need services to support us to get there. 21 These core definitions need to be expanded for people with addictions and for different age groups. For people with addiction problems, recovery involves an expectation or a hope that they can and will recover. It is a process, not a state of being. It includes both abstinence and harm minimisation approaches that have evolved over time, allowing people a choice to adopt the approach that best represents their world view. For many older people, especially those with progressive disorders, recovery may be better described by the concepts of quality of life and dignity. For children and young people, resiliency is more important than recovery, and recovery needs to focus on ensuring that developmental milestones appropriate to the child continue to be attained. When Blueprint II uses the term recovery it covers all these elements. Future focus, protecting gains Equity Improve equity for Māori, Pacific people and vulnerable populations Build on the gains made to date and embrace the new wave Holistic and whole system Mental health and wellbeing is critical to a well functioning and productive society Wellbeing Strengthen focus on prevention, promotion, and early intervention throughout life People, family/whānau centred and directed resiliency and recovery Productivity and sustainability Improve the performance of the sector to ensure value for money Accountability and evidence Use the evidence to support outcome and results based accountability Figure 1: Principles underpinning Blueprint II 21 Mental Health Commission Our Lives in Wellington: Mental Health Commission. 12 Blueprint II: Improving mental health and well being for all New Zealanders How things need to be

15 6. Directions To put the principles into action we must: 1. Respond earlier and more effectively to mental health, addiction and behavioural issues. 2. Improve equity of outcomes for different populations. 3. Increase access to mental health and addiction responses. 4. Increase system performance and our effective use of resources. 5. Improve partnerships across the whole of government. 6.1 Respond earlier and more effectively to mental health, addiction and behavioural issues There is strong evidence to show that responding earlier and more effectively can improve people s lives, avoid negative impacts on society and reduce the level and intensity of demand for services arising later It is also clear that mental health and addiction issues can impact on people at different times throughout their lives: responding earlier will mean different things for children, youth, adults and older people. Blueprint II introduces a life course approach to help show that early response is important for everyone and that intervening at key moments can have a positive impact over time. The life course approach allows us to look at the critical points in the development of mental health, addiction and behavioural issues where we can intervene earlier and more effectively. It covers the whole life course, from before birth through to older people. In particular, it focuses on the eight most common points in the lives of people with mental health, addiction and behavioural issues where there is an opportunity to identify issues and to make a real difference by intervening early. To be successful, the life course approach requires responses from the whole health sector, the broader social, education and justice sectors, as well as the mental health and addiction sector. 22 Fonagy P, Target M, Cottrell D, Phillips J and Kurz Z A review of the outcomes of all treatments for psychiatric disorder in childhood. MCH Merry S, Woulds T, Elder H, Guy D, Faleafa M and Cargo T CMDHB Infant Mental Health Report. Auckland: Counties Manukau District Health Board. Directions 13

16 Children Youth Health promotion Adults Older persons Infants Supported self care Organised mental health and addiction responses Impact of mental health and addiction on women at risk 1. Families & whānau at risk 3. Youth/adolescents (incl. -1 to +3 years, pregnancy, post natal, maternal, infant wellbeing and parenting) with emerging mental health, behavioural and addiction issues 2. Children with mental health and behavioural issues (<12 years) 5. Impact of adult mental health and addiction on families and whānau Adults and older people with high prevalence disorders, moderate to severe impact 6. Adults and older people with low prevalence, high severity disorders 8. Adults and older people with mental health and addiction disorders alongside disabilities, chronic illness and/or dementia 4. Youth/adolescents at high risk (including forensic) 7. Adults and older people involved in forensic and/or justice system Infants Children Supported self care Health promotion Youth Adults Older persons Figure 2: Life course approach The life course approach can also focus our thinking about the opportunities we have at different ages and stages to support people, families and communities to be resilient and to weather adversity. This is the domain of health promotion and supported self care the two outer sections of the diagram above. For example, for older people, effective health promotion and self care would include physical exercise programmes, social support and activities, home visits, volunteering and attention to spiritual needs. 24 Health promotion and self care is not an area where the mental health and addiction sector can take sole responsibility. It needs a broader support base including people, their families, communities, and employers alongside the health and wider social sector. 24 Ministry of Health Mental Health and Addiction Services for Older People and Dementia Services. Wellington: Ministry of Health. 14 Blueprint II: Improving mental health and well being for all New Zealanders How things need to be

17 The eight clusters covered by the life course approach and the impact of intervening at these points are: 1. Families/whānau at risk (-1 to +3 years, pregnancy, post natal, maternal and infant wellbeing, parenting) 2. Children with mental health and behavioural issues 3. Youth/adolescents with emerging mental health, behavioural and addiction disorders 4. Youth/adolescents at high risk (including forensic) 5. Adults and older people with high prevalence disorders, moderate to severe disorders 6. Adults and older people with low prevalence, high severity disorders The perinatal and infant years have a direct impact on later success in life. There is an opportunity to intervene early to support families/whānau to provide the foundation for good mental health and resiliency. Preschool to prepubescent (less than 12 years) children with behavioural disorders (including attention deficit and hyperactivity disorder, oppositional defiance, milder forms of developmental and learning disorders and conduct disorders) and their family/whānau. It represents an opportunity to provide parenting support and early intervention to substantially improve participation in education and to reduce the risk of youth and adult mental health and addiction issues and crime. Youth experience a significantly higher rate of mixed anxiety, depression and alcohol and drug use which has a significant impact on mental health and wellbeing for this group. It represents an opportunity to intervene earlier and reduce the risk of subsequent adult mental health and addiction issues. This cluster focuses on youth with significant mental health, alcohol and drug and behavioural disorders and represents an opportunity to intervene in a pathway that has the potential to lead to life-long mental health and addiction issues. It includes youth who are at risk of, or already involved with the forensic mental health or justice systems. Interventions for youth with significant mental health, alcohol and drug and behavioural disorders provide an opportunity to reduce the risk of them experiencing life-long mental health and addiction issues. Adults and older people with anxiety, depression, drug and alcohol abuse, and medically unexplained symptoms often have co-existing medical conditions, resulting in high use of health services. It represents an opportunity to increase the resiliency of this population, reduce the costs of secondary and tertiary medical/surgical services provision and reduce the society-wide burden of poor health, loss of employment and loss of independence. Adults and older people with severe mental health and addiction conditions, particularly where they are enduring, are at risk of substantially reduced life expectancies, higher morbidity and reduced social and employment participation. Intervening with more evidence-based effective interventions, in particular talking therapies and supported employment initiatives represents an opportunity to strengthen recovery, reduce morbidity and improve social inclusion. Directions 15

18 7. Adults and older people involved in forensic and/or justice system 8. Adults and older people with mental health and addiction disorders alongside chronic illness and/or dementia Where high severity mental health and addiction issues overlap with criminal behaviour, it represents an opportunity to support more comprehensive and integrated responses across the justice system and mental health and addiction services. This results in better health, reduced reoffending, reduced benefit use and increased employment. For adults and older people there is an opportunity to integrate mental health and addiction interventions with health and wider social sector responses to maintain functioning and independence and to slow decline. These opportunities for improving mental health outcomes for these eight population groups are all connected: more effective earlier action reduces the level and intensity of demand for services arising later. The use of this framework does not imply that, for example, every child with a conduct disorder will become an offender, or that parents with mental illness are placing their children at risk. What the framework does is use the evidence base to identify those groups of people who are most at risk and where intervention can be successful at a population level. For example research tells us that for the 5 10% of children with the most severe conduct and behavioural problems, early intervention has the potential to reduce adult crime activity and associated poor life outcomes for those children by 50 70% Improve equity of outcomes for different populations Mental health and addiction outcomes vary widely across different population groups in New Zealand. These groups include Māori, Pacific peoples, refugees, lesbian, gay, bisexual and transgender people, people who are deaf, people in detention, people with intellectual disabilities, and people who live in rural areas. The outcomes are based on a complex mix of socioeconomic, ethnic, cultural, environmental and geographic factors. All New Zealanders should have the same opportunity to achieve mental health and wellbeing. Sustained efforts are required to achieve more equitable outcomes for those groups. There is no single way to ensure improved outcomes for different population groups. Many have their own distinctive world views and there are unique ways of meeting their needs. A balance is needed between providing services that are tailored for a particular group s needs, while ensuring that a breadth of mainstream services are still available. Poverty, inadequate housing, low levels of education and unemployment put people at greater risk of developing mental health and addiction issues: the conditions people face in their lives shape whether they feel safe, secure and supported at home and in their communities. 26 Collaborative efforts across a range of sectors are required to address the social determinants of mental health. 25 Heckman J Invest in the Very Young. Chicago, Illinois: Ounce of Prevention Fund and University of Chicago Harris School of Public Policy Analysis. 26 Mental Health Commission of Canada Mental Health Strategy for Canada. Canada: Mental Health Commission of Canada. 16 Blueprint II: Improving mental health and well being for all New Zealanders How things need to be

19 6.2.1 Māori The findings from Te Rau Hinengaro 2003/04 27 show that Māori have higher overall rates of mental health disorders than Pacific people and non-māori people and that this higher level of need for services is not currently being met. Sustained, ongoing efforts are required to develop pathways of care, environments and a workforce that are more effective for Māori mental health service users and their whānau. Whānau Ora brings together Māori aspirations around mental health and provides an approach which builds whānau capability and provides support for Māori families to achieve their maximum health and wellbeing. 28 For services to be effective for Māori they need to: Meet the broader health and mental health needs of the service user in the context of their whānau. Understand the circumstances of the service user s life and goals. Recognise a Māori world view in service delivery. Be culturally appropriate. Address the barriers to Māori accessing mental health and addiction services. Increase access for Māori to appropriate mental health and addiction services Pacific peoples The findings from Te Rau Hinengaro also show that Pacific peoples carry a higher burden of mental illness than the general population. The profile in relation to Pacific peoples mental health and addiction is complex, with compounding risk and protective factors that are different from other ethnic groups. Access rates to services are low compared to need, particularly for Pacific children and adolescents. When Pacific peoples do access services, evidence shows it tends to be a later presentation, at the more severe end of the continuum. Pacific peoples world views and identity are based on a collective approach, governed by a complex set of interrelationships between individuals, their families and communities. Over the past decade Pacific models of mental health care and the philosophical value systems that underpin them have been developed. These models emphasise the importance of understanding Pacific concepts such as the use of language, family and spirituality as a key component of Pacific models of care that exist alongside the physical, mental and social aspects of a person s wellbeing. For services to be effective for Pacific peoples they need to: Meet the broader health and mental health needs of the service user in the context of their families. Understand the circumstances of the service user s life and environment. Recognise Pacific world views in service delivery. Be culturally appropriate. Address the barriers to Pacific peoples accessing mental health and addiction services. Increase access for Pacific peoples to appropriate mental health and addiction services. 27 Oakley Browne M, Wells J, Scott K (eds) Te Rau Hinengaro: The New Zealand Mental Health Survey. Wellington: Ministry of Health. 28 Mauriora Ki Te Ao Living Universe Limited Whānau Ora Integrated Services Delivery. Wellington: Ministry of Health. Directions 17

20 6.3 Increase access to organised mental health and addiction responses The original Blueprint focused on reaching a section of the population with the highest and most complex mental health and addiction needs estimated to be 3% of the population in There is now growing acknowledgement of: The wider prevalence of mental health and addiction issues with significant impacts right across society. The impact of less severe mental health and addiction issues on people s overall health and their ability to function at home and at work. The importance of early intervention, prevention and the promotion of mental wellbeing. Organised mental health and addiction responses Recovery and resilience focused responses provided by the health and other sectors and covering self care, primary, community and specialist settings. To be counted as an organised response it must be planned, reviewed and measured. For example, using an online self help programme would not qualify if it was self initiated; it would qualify if it was part of a planned and monitored response through primary care. As a result, Blueprint II broadens the definition of the mental health and addiction sector to include primary care and broadens the delivery of responses beyond those most severely affected. It calls for earlier identification of mental health and addiction issues in primary care, and access to effective responses through stepped care delivered across the wider spectrum of services. Blueprint II envisages a future where no one will be turned away because they do not fit criteria for services. This will require greater access to effective organised mental health and addiction responses than we have achieved to date. Blueprint II also identifies the need to integrate mental health and addiction services into the broader health system and across social services. This broader approach has significant implications for access to organised mental health and addiction responses. The initial Blueprint used the epidemiological evidence then available, across six age groups and four levels of service to calculate a set of likely access targets for each age group. The result of this modelling was confirmation that the best current estimate of the percentage of the total population who needed access to publicly funded specialist mental health services in any six months period was 3%. The mental health and addiction sector needs to maintain and increase responsiveness to people with the highest needs. But given the growing evidence of prevalence and impact and the demonstrated benefits of early intervention both early in the life-course and early in the development of mental health and addiction issues it is clear that the new integrated mental health and addiction system where no one is turned away will move us well beyond the 3%. It will also increase access to effective responses delivered in primary care as well as in specialist settings. We need goals to shift the focus from accessing services to responding in ways that make a difference in people s lives. These goals should drive: Increased recognition of people and families/whānau at high risk of mental health or addictions issues. Provision of organised mental health and addiction responses across primary and community settings as well as specialist services (stepped care). Models of care that ensure people can access the right services when they need them. Effective partnerships with cross-sector partners and recognition of their contribution to meeting the mental health and addiction needs of our population. The best use of all the resources we have available, including those within the wider general health sector and beyond. How we respond to need across the life-course. 18 Blueprint II: Improving mental health and well being for all New Zealanders How things need to be

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